Overview

Electronystagmography/
and Assessment of
Videonystagmography
Balance Functions

Dr. Sujeet Kumar Sinha

Lecturer
AIISH, Mysore
 Why You should do ENG?

 Vestibular system lesion ?

 Peripheral or Central
 If Peripheral -- R / L / Bil.
 If Central - Where?
 Static / Progressive / Recovery.
Fundamentals of ENG
CORNEORETINAL POTENTIALS
 Nystagmus

se

Fast Phase
Pha
Slo
Fast Phase

w
Ph

Slo
as
e

Duration of the nystagmus

 Electrode Placement

Ground
Positive (+ve)

Positive (+ve) Negative (-ve)

Negative (-ve)
Basic Principle of ENG
 Precautions before the testing:

• Avoid alcohol and certain other drugs at least 48 hrs

before the testing
• EAM must be examined
• Look for perforation of TM
• Should not take food at least 6-8 hrs before testing
 Calibration of Instrument

Light Bar

10 deg
 Calibration of Instrument

8 mm
10 mm =160 uv
=200 uv
 ENG test Battery

Peripheral tests Central Tests

Saccade Test
Positional Tests

Gaze Test
Proxysmal
nystagmus test Pendulum
Tracking

Spontaneous
Caloric Test Nystagmus

Optokinetic
 Positional Tests

Eyes should be closed during the test to avoid visual suppression

Classification of Positional Nystagmus
• Type-1. Direction Changing
• Type-2. direction fixed
• Type-3. Irregular or variable
Proxysmal Nystagmus Test/Dynamic positioning
test/Dix Hallpike test
Interpretation
 BPPV Central Nystagmus

Latent period 2-10 sec None

Adaptation Within 30 sec persists

Vertigo Present, severe Usually absent or

Mild

Direction of Towards undermost Variable

Nystagmus ear

Incidence Common Rare

 Caloric Test

• Thermal stimulus used

• Temperature selected is 44 & 33 deg C
• Irrigation of water done in following order:
Right-44, Left – 44, Right- 30,Left-30
• Patient is kept alert
 Three types of irrigation used

 Open water irrigators

 Closed loop irrigators
 Air caloric irrigators
 Range of culmination frequency/30 seconds for all four
caloric stimulation (AIISH, Vertigo Clinics )

Caloric stimulation Range of culmination frequency per 30 seconds

Right warm 22 – 59

Left warm 20 – 70

Right cold 21 – 51

Left cold 22 – 64
Canal (R 44C + R 30C) — ( L 44C + L 30C) x 100
=
Paresis (R 44C + L 44C+ R 30C + L 30C)

(30+50) — (20+20) 40
x 100 x 100 = 33.33%
= =
(30+20+50+20) 120
 Right Beating Nystagmus

Right 44 Left 30

Right Ear Left Ear

Right 30 Left 44

Left Beating Nystagmus

Butterfly Chart
Optokinetic Test

+300 to 00

-300 to 00
 Gaze Test

• Patient is asked to look 30º to the right, left, up & down

• Duration: 30 mins , Recording in each position
• Nystagmus on gaze deviation suggestive of central lesion
 Spontaneous Nystagmus

• Done during caloric test

• Normal patient & patient with peripheral lesion should
be able to supress the nystagmus
• First recorded with eyes closed & then eyes opened with
eyes fixate on a target
• Recorded for one minute.
 Interpretation

 Left beating/right beating with eyes closed, frequency

more than 19 betas per 30 sec suggests right/left vestb
lesion
 Left beating/right beating with eyes closed, frequency less
than 19 betas per 30 sec-clinically insignificant
 No Nystagmus with eyes closed but in open condition
Nystagmus present- central lesion
 PENDULUM TRACKING TEST

• Evaluate smooth pursuit

• Tracks 10 stimulus cycles, Latter 5 are evaluated
• Sway: 30º visual angle
• Speed: less than 50º/sec
• Records: 4 types
 Things to remember

 In ENG you record the corneoretinal potentials.

 Each subject is different.
 Mainly gives information about HSCC.
 Artifacts from muscle potentials.
 Cannot pick up torsional movement.
 Cannot record when no corneoretinal potentials.
Videonystagmography
 The term “video-oculography” was introduced
spontaneously by one of the authors during a
presentation at a local meeting in Berlin (Treffpunkt
Medizintechnik) in 1988, when a visiting journalist
insisted that the video-based technique must have
an appropriate, easy-to-remember title.
Basic Instrumentation
Frenzel glasses consist of the
combination of magnifying
glasses (+20 lenses placed in
front of the patient), and a
lighting system. When Frenzel's
goggles are placed on the
patient, and the room lights
darkened, nystagmus can easily
be seen because the patients
eyes are well illuminated and
magnified, and because fixation
is removed as the patient can
hardly focus through magnifying
glasses on a dark room.
 Digital Imaging sensors

 Purkinje sensors
 Limbus Sensors
 Purkinje sensors

• Purkinje images are reflections of illumination lights

on the different optical surfaces of the eye.
• However, Purkinje trackers require an elaborate
setup, and as a result are rarely employed.
 Limbus Sensors

• The reflectivity of the sclera is much larger than the

reflectivity of the darker iris.
• Over short periods such systems can achieve an
accuracy of about 1 deg horizontally and 2 deg
vertically, which is often sufficient for vestibular
screening tests.
 How VNG works??

• The camera forms a digital image of the eye, as

well as of reflections on the optical surfaces of the
eye. Then computer algorithms are used to identify
particular structures in this image, in most cases first
the near-circular pupil. Together with appropriate
calibration procedures, the orientation of the eye
with respect to the camera is then calculated.
BRIGHT PUPIL TECHONOLOGY
DARK PUPIL TECHONOLOGY
The Whole Testing is similar to the ENG.
 If u are still awake,
please wake up the
person sleeping
next to you.
 ACKNOWLEDGMENTS

ORGANISERS
HOD-AUDIOLOGY, AIISH
DIRECTOR, AIISH